In a hurried and pressure-ridden work environment, such as a surgical operating room, there is always a risk for errors to occur. Medication errors may be particularly at risk in the event of an emergency administration of an injectable drug, e.g., while a patient is coding. This is because performing the appropriate calculations to account for drug concentration and volume to be administered based on patient physical characteristics can be difficult under heightened stress conditions. In fact, the steps involved in drug dose calculation, preparation, and administration are constantly identified as steps in pediatric resuscitation that are prone to error, and may be associated with significant morbidity and/or mortality in emergency situations.
Moreover, medication errors related to emergency administration of an injectable medication are not limited to surgical operating rooms. Health care arenas where emergency administrations (to adults, children, or both) occur infrequently are typically staffed by personnel who are less than ideally familiar with calculation, preparation, and administration of injectable medications under emergency conditions.